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Welcome to Global Integrated Reimbursement Services’ blog. The purpose of our blog is to allow access to a repository of issues that our company tracks regarding the reimbursement for pharmaceuticals, medical devices, diagnostics, biologics, and biosimilars. Also, it shows you how we can assist you in these areas.

Let GIRS Assist you to Analyze the Impact of the 2018 Medicare Inpatient Rehabilitation Facilities Payment and Policy Changes

On July 31, 2017, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the 2018 payment and policy changes for Medicare Inpatient Rehabilitation Facilities (IRF.)

The changes to be expected from this rule include updates to IRF Prospective Payment System (PPS) rates, removal of 25% payment penalties for late transmissions, adjustments to the 60% rule of presumptive methodology, technical process revisions, and the IRF Quality Reporting Program.

In the following, we review each of these changes in more detail.

  • Updates to IRF PPS rates:
    IRS PPS rates will reflect a 1% increase factor, in addition to an approximate 0.1% decrease to aggregate payments.
  • Removal of 25% Payment Penalties:
    IRF PPS rates currently invoke a 25% payment penalty on transmissions that are not submitted in a timely manner. These penalties will no longer apply beginning FY 2018.
  • Adjustments to the 60% Rule of Presumptive Methodology:
    In order to obtain, and retain, classification as an Inpatient Rehabilitation Facility under Medicare and Medicaid guidelines, a 75% threshold compliance standard was adopted on May 7, 2004. This rule stipulated that “a minimum percentage of a facility’s total inpatient population must require treatment in an IRF for one or more of 13 medical conditions listed in 42 CFR 412.29(b)(2).” Beginning July 1, 2006, this rule was revised to decrease the compliance threshold percentage to 60%, and is now knows as the 60% percent rule. After the adoption of the ICD-10-CM medical code set on October 1, 2015, CMS began a comprehensive analysis of the presumptive methodology lists utilizing the ongoing input of stakeholders and clinicians. Based on that review, the following revisions will be made to the 60% rule beginning in FY 2018:

    1. ICD-10-CM diagnosis codes for traumatic brain injures (TBI) and hip fractures will now be included
    2. Any case which contains two or more of the ICD-10-CM codes from three major multiple trauma lists in the specified combinations will now be included
    3. Proposed removal of certain ICD-10-CM codes from the 60% rule will be put on hold at this time, as analysis continues.
  • Technical Process Revisions:
    1. CMS is finalizing the removal of a swallowing status from the IRF-PAI. This item is a duplicate of another recently added item in the Quality Indicators.
    2. Finalizing a formal process for updates to the ICD-10-CM codes used to determine the 60% rule compliance threshold.
    3. Finalizing the use of patient height and weight to calculate BMI, and use it to count lower extremity joint replacement for patients with a BMI above 50 as a qualifier for the 60% rule compliance threshold.
  • IRF Quality Reporting Program:
    CMS is revising, replacing, or removing the reporting requirements of any IRF including pressure ulcer measures, All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge, and the public display of six additional quality measures on the IRF website. The final FY 2018 Inpatient Rehabilitation Facilities changes can be viewed at

    Inpatient Rehabilitation Facilities and patient providers may utilize our InContact Reimbursement Hotline™ to allow our dedicated reimbursement team to play an invaluable role in submitting clean claims, as well as other payer requirements. Contact us today so that we may assist you with updating your billing guides.